HomeMy WebLinkAboutSeptic Pumping Slip - 15 LONG PASTURE ROAD 3/14/2016 (2) � Commonwealth of Massachusetts
6 City/Town of North Andover
System Pumping Record _
Form
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CM 15.351.
A. Facility Information
Important:When 41T
filling out forms 1. System Location:
on the computer, �.
use only the tab
key to move your Address
cursor-do not North Andover Ma 01845
use the return — -------- ......
key.
City/Town State Zip Code
2. System Owner:
ratr
k_ _
Name
mtwn
_.. - ...... -.
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping CSat�e�..-�'�-� 2. Quantity Pumped: Gauons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ YesNo
5. Condition of System:
t
6.(—, stem Pumped By:
--------.........
Name Vehicle License Number
Ste .
Company
7. Location where contents were disposed:
Stern art's Pre-treatment Plant, 20 o. M adford, Ma 01835
Sgt�at r auler
Date
wM /
--
Signatur of Receiving Facility Date
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